Microsurgical resection of brain metastases: rationale, appropriateness and local control

OBJECTIVE: To summarize data on indications for microsurgical resection of brain metastases, effect of resection technique on local control and leptomeningeal dissemination, as well as the role of stereotactic radiosurgery in improving local control. MATERIAL AND METHODS: A descriptive review of data on surgical treatment of brain metastases was performed. We reviewed the PubMed/MEDLINE, the Cochrane Library (CENTRAL), PubMed Central, and eLIBRARY/RSCI databases between 2000 and January 2025 using the keywords "brain metastases", "en bloc resection", "piecemeal resection", "local control", "leptomeningeal disease", "preoperative SRS" and "postoperative SRS". Clinical studies, systematic reviews, meta-analyses, guidelines, and consensus documents were included. Studies on primary central nervous system tumors, samples ≤10 patients, and publications without extractable clinical outcomes were excluded. RESULTS: The first part of the review considers indications for microsurgical resection in relation to clinical goals, survival and functional status. Surgery is reasonable for symptomatic large lesions, mass effect, diagnostic uncertainty, local recurrence, or complications after radiotherapy. Surgical technique should account for growth pattern of brain metastases: en bloc resection and, in selected cases, extended resection of peritumoral zone may improve local control. Retrospective data consistently associate piecemeal resection with higher risk of leptomeningeal dissemination, particularly for posterior fossa lesions and metastases adjacent to cerebrospinal fluid pathways. CONCLUSION. S: Urgical treatment is presented as a component of a personalized multimodal strategy. Decision-making on surgery should rely on survival prognosis and likelihood of clinically meaningful benefit. When technically feasible, en bloc resection may be considered as a preferable approach, especially when the risk of leptomeningeal dissemination is clinically relevant.